Waleed Ammar

Value of duplex scanning in differentiating embolic from thrombotic arterial occlusion in acute limb ischemia

BACKGROUND Management of acute limb ischemia (ALI) is largely based on the etiology of arterial occlusion (embolic vs. thrombotic). To our knowledge, the ability of duplex scanning to differentiate embolic from thrombotic occlusion has not been previously reported. PURPOSE To determine the ability of duplex scanning to differentiate embolic from thrombotic acute arterial occlusion. METHODS We prospectively recruited 97 patients (50.3 ± 19.7 years; 55% males) with 107 nontraumatic ALI in native arteries. All patients underwent surgical revascularization. Preoperative duplex scan detected arterial occlusion in the following arteries: iliac (11), femoral (38), popliteal (38), infrapopliteal (3), subclavian (3), axillary (1), brachial (9), and forearm arteries (4). We measured the arterial diameters at the site of occlusion (d(occl)) and at the corresponding contralateral healthy side (d(CONTRA)). The difference (Δ) between the two diameters was calculated as d(OCCL)-d(CONTRA). Duplex scan was also used to assess the state of the arterial wall whether healthy or atherosclerotic and the presence of calcification or collaterals. According to surgical findings, limbs were classified into embolic (E group=55 limbs) and thrombotic (T group=52 limbs) groups. RESULTS Both groups were comparable regarding age, diabetes, hypertension, smoking, atrial fibrillation, and time of presentation. The status of arterial wall at the site of occlusion and presence of calcification or collaterals were all similar in both groups. Δ in the E group was 0.95 ± 0.92 mm vs. -0.13 ± 1.02 mm in the T group (P<.001). A value of ≥ 0.5 mm for Δ had 85% sensitivity and 76% specificity for the diagnosis of embolic occlusion (CI 0.72-0.90, P<.001), whereas a value of less than -0.5 mm for Δ had 85% sensitivity and 76% specificity for thrombotic occlusion (CI 0.72-0.90, P<.001). CONCLUSION In acute arterial occlusion, ≥ 0.5 mm dilatation or diminution in the occluded artery diameter is a useful duplex sign for diagnosing embolic or thrombotic occlusion, respectively.

Acute limb ischemia: Role of preoperative and postoperative duplex in differentiating acute embolic from thrombotic ischemia

BACKGROUND Acute limb ischemia (ALI) represents an emergency in which delayed intervention results in significant morbidity, and potentially, death. PURPOSE To assess the role of duplex in differentiating embolic from thrombotic ALI. METHODS AND MATERIALS We prospectively recruited 57 patients; with 62 non-traumatic ALI. We measured the diameter at the occluded site (dO) and the corresponding contralateral healthy side (dC). The absolute (∆) and percent change (∆%) between the two diameters were calculated as: (dO-dC) and [(∆/dC)×100] respectively. According to the reference standard (contrast angiography or surgery), limbs were classified into embolic (E-group:37 limbs) and thrombotic (T-group:25 limbs) groups. Postoperative duplex was done in 34 patients after embolectomy and the absolute (∆P) and percent change (∆P%) between the postoperative (dP) and preoperative (dO) diameters at the occlusion were calculated as: (dP-dO) and [(∆P/dO)×100] respectively. RESULTS The baseline clinical characteristics were similar between both groups. However, in the E-group, (∆%) was 21.96±17.53% vs. -11.03±16.16% in the T-group, (p<0.001). A cutoff value of >1.41% for (∆%) had 100% sensitivity and 76% specificity for the diagnosis of embolic vs. thrombotic occlusion with AUC 0.95 (95% CI: 0.901-0.999, p<0.00l). Postoperatively (∆P%) was -11.8±8.2% with a significant negative correlation found between (∆) and (∆P); Spearmans coefficient (rho)=-0.912, P<0.001. CONCLUSIONS A cut off value of 1.41% as percent dilatation or diminution in the diameter of occluded artery is the most important duplex sign for predicting embolic or thrombotic ALI respectively. Postoperative reduction in the diameter of occluded artery after embolectomy confirms this sign.

Assessment of left ventricular regional wall motion abnormalities using regional time-volume curves obtained by real time three-dimensional echocardiography

Background Three-dimensional echocardiography provides a volumetric measurement of global and regional left ventricular (LV) function. It avoids the subjectivity of 2D echocardiography in the assessment of regional wall motion abnormalities (RWMA). Purpose Evaluate the feasibility and practicality of 3D echocardiography in the evaluation of ischemic patients with abnormal regional LV contractility. Methods The study included 40 patients with ischemic heart disease and RWMA as well as 30 control subjects. They underwent routine clinical examination and conventional 2D echocardiographic assessment. Segments were categorized as; normal, hypokinetic; akinetic or dyskinetic. Three-dimensional echocardiographic images were acquired and later on analyzed offline. Global LV function was semi-automatically calculated by the machine using volumetric measurements. Regional LV function was calculated manually for the 17 LV segments by detecting the end-diastolic (EDD) and end-systolic (ESD) points on the specific segment volume curve and the regional ejection fraction (EF) was calculated by the following formula {(EDDx-ESDx)/EDDx}, where x represents the specific segment. Regional EF was compared between patients and control subjects. Results The mean age was 55.0 ± 8.0 and 32.6 ± 8.5 years (P < 0.001) in patients and control groups, respectively. No statistically significant difference in EF between 2D and 3D images (47.3 ± 10.5 vs 48.0 ± 8.0, p = 0.6). There was a good correlation between the 2D-RWMA and 3D-regional EF, and this correlation was consistent in the whole 17 segments. Conclusion Three-dimensional echocardiography is an easy, non-invasive and objective tool to detect regional wall motion abnormalities in ischemic patients. It shows comparable results with conventional 2D images with the advantage of quantitative assessment of regional myocardial function.

Early postoperative paravalvular leak among Egyptian population: An observational study

Objectives Several reports described the incidence of postoperative paravalvular leakage (PVL) early after valve replacement surgery, however, there is a paucity of data regarding the outcomes and complications correlated to the severity of PVL. The aim of the current study was to evaluate the incidence, causes, and short term outcome of early postoperative PVL. Methods Data were collected from patients presenting to the cardiovascular department at Cairo University Hospital for aortic and/or mitral valve replacement surgery from May 2014 to May 2015. Transthoracic echocardiography (TTE) was done for all patients early postoperative. Transesophageal echocardiography (TEE) was done if diagnosis was not confirmed by TTE. All patients with detected PVL were subjected to TTE and TEE after a 3 month follow-up period. Results Two hundred patients were enrolled in the study. Seventy five percent of patients were known to have rheumatic heart disease, while 16.5% had infective endocarditis. The mitral valve was replaced in 40% of patients, the aortic valve was replaced in 36%, and other patients had both valves replaced. Early postoperative period PVL was detected in 25 patients. The most common underlying etiologies were rheumatic heart disease and infective endocarditis. PVL was common in patients with both valves replaced compared with either mitral or aortic valve replacement. Infective endocarditis as underlying valve disease was significantly high in patients with PVL compared with those without (p < 0.001). Conclusion The incidence of PVL was high in patients with both valves replaced compared with either mitral or aortic valve replacement. Moreover, every patient with PVL should be properly investigated for infective endocarditis. Surgical intervention, although associated with high morbidity and mortality, reduces PVL recurrence.

Haemoglobin A1c as a marker predicting extent and severity of coronary artery disease in non-diabetic patients.

Objective Lowering haemoglobin A1c (HbA1c) was shown to be associated with reduction of microvascular, neuropathic and possibly macrovascular complications in diabetic patients. However, in non-diabetic patients, few reports have examined the relation between HbA1c and extent of coronary artery disease. The aim of this study was to examine the relationship between HbA1c level and severity of coronary artery disease (CAD) in non-diabetic patients scheduled for elective coronary angiography. Methods We prospectively studied 408 consecutive non-diabetic patients with or without history of previous myocardial infarction who were scheduled for conventional coronary angiography. HbA1c was measured in all patients at the time of admission. Severity of CAD was assessed by the Gensini score. Gensini score > 30 was considered severe coronary atherosclerosis. Patients were divided into two groups: the high-risk group (HbA1c, 5.7-6.4%) and the low-risk group (HbA1c, < 5.7%). Results Patients in the high-risk group had a higher Gensini score (45.1 ± 36.7 vs 26.8 ± 26.0, P< 0.001). Patients with a Gensini score > 30 had higher values of HbA1c (6.0 ± 0.48 vs 5.75 ± 0.54, P< 0.001). HbA1c showed a positive correlation with the Gensini score. HbA1c value of 5.85% showed a sensitivity and specificity of 70 and 50%, respectively, for prediction of severe coronary atherosclerosis. Conclusion HbA1c is significantly associated with severe coronary atherosclerosis in non-diabetic patients.